Plugging the black hole
Column from Medical Independent on 8 October 2015
When Leo Varadkar took up post as health minister, he prioritised securing an ‘adequate’ budget for health. He did this in the hope that he could break the cycle of over-spending in health. Come early December 2014, the rumours about the extent of the supplementary budget required for health were quashed when a whopping €680 million supplementary budget was announced.
Speaking on the day of its official publication, Minister Varadkar explained that more than €500 million of the €680 million was needed due to “increased levels of medical activity, drugs and therapies, medical appliances, the cost of State claims, and frontline staff” in 2014. He also said that these driving costs had “already been included in the base for next year’s expenditure”.
Yet expectations are that the supplementary budget required for this year will be even higher than last year, thus blowing a hole in the Minister’s aspiration to break the cycle of overspending in health.
The latest official figures show a health overspend of €270 million by July.
In mid-September, a second meeting of the Emergency Department Task Force implementation group was held. There, the Minister kicked ass with those around the table about the slowness in delivering the actions outlined by the Task Force report. He questioned how the additional €100 million he had secured for reducing delayed discharges and implementing the report was being spent. He warned those responsible for delivering on the report’s recommendations that it would be extremely difficult for him to secure any more money for health unless results were tangible.
So how is it that the €100 million allocated to tackle emergency department (ED) overcrowding and even the ‘adequate’ budget for health in 2015 is not enough? And that this year’s supplementary budget could be a record high?
Crude staff and pay cuts mean that staff shortages persist across the public health system
Since 2006, the Irish population has grown by 8 per cent, the number of people over 65 years of age has increased by 14 per cent, while those aged over 85 years has increased by 30 per cent. The number of over-85s needing treatment in a hospital bed was up 74 per cent when 2014 is compared with 2006. In some EDs, over half of all admissions are now over 70 years of age.
The longer these people are left inappropriately on trolleys in EDs, the longer their stay in hospital, the less likely they will return home, the more likely they will need nursing home care.
The €100 million allocated has reduced the waiting times for nursing home care from 14 weeks to four and the numbers of delayed discharges are down from about 800 to 586 in mid-September. But high numbers and wait times in EDs persist, as solving the ED crisis requires solving problems across the health system. And it’s just not possible to solve these tricky issues in just a few months with €100 million.
Better resourcing of primary and community care could prevent some of these older people ever ending up in EDs. There needs to be other ways of meeting the health needs of older people presenting at our EDs. Why can’t they have direct access to hospitals’ through acute medical assessment units?
There are 140 more doctors and 400 more nurses in EDs now than there were a year ago. Having these on the floor making decisions is one way to reduce lengths of stay as early, good decisions are made on the clinical care required. There are more tests and treatments available in our hospitals now than 10 years ago, which in many instances are contributing to better diagnosis, treatment and health outcomes. But it is likely that some patients are being over-tested or over-treated.
Crude staff and pay cuts mean that staff shortages persist across the public health system and holes are still being plugged with extremely expensive, less experienced agency staff.
The amount of money spent on health as a proportion of the population (per capita health spend) is now at 2005 levels. We are now well out of kilter with international health spending. Given the rising costs of medical inflation, especially the costs of some high-tech drugs; the push for more and better patient care; and the prolonged negative impact of austerity on the health systems — most evident in reduced bed capacity and staff shortages — then a historically high supplementary health budget should not be a surprise to the Minister or anyone else.
As the HSE, the Departments of Health and Public Expenditure and Reform haggle over the health budget for 2016, a significant mind-shift is needed. Instead of seeing health as the bottomless pit without returns, they need to see the health system as an investment in all our population, especially the sickest and those who work in it. And at the same time make sure better care is being provided with the money spent. That might allow us to increase our health budget to bring us back up to the norm with international health spending trends.
Only then can the Minister aspire to not needing supplementary budgets in the years ahead.